Hospital Technical Document CMT · 2024 CPG · Rev. 01

Neonatal Screening Protocol

Congenital Muscular Torticollis: from screening to follow-up.

A hospital implementation protocol based on the 2024 CMT CPG from the APTA Academy of Pediatric Physical Therapy, adapting the screening, classification and referral pathway to the routine of the maternity ward and the pediatric outpatient clinic.

0–3

Days of life for the first evaluation

Grades on the CMT Severity Grading Scale

Clinical recommendations (Action Statements)

Support material for clinical protocol committees, technical management and pediatric physical therapy services.

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TECHNICAL DOCUMENT FOR HOSPITAL MANAGEMENT AND PEDIATRIC PHYSICAL THERAPY SERVICES SCIENTIFIC BASIS: 2024 CMT CPG — APTA ACADEMY OF PEDIATRIC PHYSICAL THERAPY

Neonatal Screening Protocol

The window to treat congenital muscular torticollis closes in months, not years.

The APTA Academy of Pediatric Physical Therapy's 2024 clinical guideline shows a clear dose-response relationship: the earlier cervical range of motion is assessed and classified, the greater the chance of full resolution — without surgery, without botulinum toxin, without craniofacial sequelae.

Recommended evaluation

First 2–3 days of life

CMT prevalence

3.9% to 16% of newborns

Non-muscular causes

Up to 18% of asymmetry cases

Prognosis for full resolution, by age at start of physical therapy

Data from Petronic et al., cited in the 2024 CMT CPG — full resolution defined as absence of head tilt and complete rotation/lateral flexion range of motion.

98,6%

ONSET < 1 MONTH

Average duration: 1.5 months

89%

ONSET 1–3 MONTHS

Average duration: 5.9 months

62%

ONSET 3–6 MONTHS

Average duration: 7.2 months

19%

ONSET 6–12 MONTHS

Average duration: 9.8 months

Source: Petronic I, et al. Eur J Phys Rehabil Med, 2010 — cited in Sargent B, Coulter C, Cannoy J, Kaplan S. 2024 CMT CPG, Pediatr Phys Ther 2024;36:370–421.

Why early screening matters

Every week of delay changes the infant's clinical outcome

The guideline recommends that health professionals and caregivers assess and document the presence of cervical, facial or cranial asymmetry as early as the first 2 to 3 days of life (Action Statement 2), with immediate referral to a pediatric physical therapist as soon as asymmetry is noted (Action Statement 3).

21,75×

Odds of CMT (odds ratio) when facial asymmetry is present at birth

Chen MM et al., 2005 — n=1021

Grade A

"Strong" recommendation strength for early referral — the highest rating in the 2024 guideline update

Action Statement 3, 2024 CMT CPG

Reduction in the rate of conversion to surgery when intervention begins before 3–4 months

Demirbilek & Atayurt, 1999; Cameron et al., 1994

The operational problem the guideline itself describes

Measuring a newborn's cervical range of motion today is an impractical process

The 2024 CMT CPG openly acknowledges a gap between the clinical recommendation and practice in maternity wards and outpatient clinics: objective measurement of cervical range of motion (ROM) requires instruments and staffing that many services do not have available at the time of screening.

Direct quote from the guideline

"The clinical challenge of using an arthrodial protractor or goniometer is that they require, at minimum, 2 adults [...] A third person may be needed to hold the instrument in place. [...] Research from New Zealand and Canada suggests that physical therapists frequently estimate visually rather than measure with an instrument — with the greatest barrier being the absence of a reliable, time-efficient tool."

2024 CMT CPG — "Examine Body Structures" section, Action Statement 8, references 58 and 60

01Manual goniometry requires 2 to 3 clinicians at the same time
02Visual estimation has insufficient reliability for stand-alone clinical use
03Lack of photographic/objective records hinders auditing and tracking progress over time
04Without objective data, the CMT Severity Grading Scale cannot be applied correctly

Action Statement 9 — Classification

CMT Severity Grading Scale (8 grades)

The guideline recommends classifying every suspected or confirmed case into 1 of 8 grades, combining three objective factors: age at evaluation, the difference in passive cervical rotation between sides, and the presence of a sternocleidomastoid (SCM) muscle mass. This classification guides prognosis, visit frequency and the need for referral.

GRAU 1

Early mild

0–6 months · difference < 15°

GRAU 2

Early moderate

0–6 months · difference 15–30°

GRAU 3

Early severe

0–6 months · difference > 30° or SCM mass

GRAU 4

Later mild

7–9 months · difference < 15°

GRAU 5

Later moderate

10–12 months · difference < 15°

GRAU 6

Later severe

7–9 mo: difference > 15° · 10–12 mo: 15–30°

GRAU 7

Later extreme

7–12 mo with SCM mass, or 10–12 mo with difference > 30°

GRAU 8

Very late

> 12 months · any asymmetry

Low complexity Moderate complexity High complexity Specialist referral

Recommended care pathway

From the maternity ward to case closure

Adapted from the early identification and referral algorithm (Figure 1) and the classification and management decision tree (Figure 2) of the 2024 CMT CPG, marking the points where objective digital measurement replaces steps currently done by visual estimation.

Day 0 to 3 — Maternity ward

Parent education and visual/postural screening of the newborn

Nursing, obstetrics or pediatric staff observe facial, cranial and postural symmetry, and provide guidance on supervised tummy time (Action Statements 1 and 2).

Day 0 to 3 — If a risk sign is present

3D skull scanning and objective cervical measurement

Newborns with risk factors (breech birth, macrosomia, primiparity, visible facial asymmetry) are scanned with an iPhone + BS3D mount and have cervical range of motion measured with a digital goniometer, avoiding reliance on visual estimation alone.

Tool: BS3D + GonioBaby

Week 1

Referral to the pediatrician and the pediatric physical therapist

Every case with postural preference, reduced cervical ROM, an SCM mass or craniofacial asymmetry is referred simultaneously to the pediatrician and to a physical therapist experienced with infants (Action Statement 3, Grade A recommendation).

Initial physical therapy evaluation

Examination of the 7 body structures and severity classification

Passive and active ROM, functional strength, pain, skin, muscle mass and craniofacial asymmetry are documented; the result feeds the CMT Severity Grading Scale (Action Statements 8 and 9), now with a digital record attached to the chart.

Record: Baby Symmetry Platform

Ongoing follow-up

Periodic reassessments with the same instrument

ROM progress is re-measured throughout treatment with the same digital method, allowing standardized comparison of values and informing decisions about intensifying the intervention or a referral for botulinum toxin/surgery (Action Statement 15).

3 to 12 months after discharge

Recurrence reassessment

Final evaluation to rule out CMT recurrence and motor delay, especially at the onset of walking (Action Statement 17), with the complete history available on the platform.

Technical Annex — Reproduction authorized by the APTA Academy of Pediatric Physical Therapy

The guideline's two original algorithms, in full

The 2024 CMT CPG explicitly authorizes its reproduction for educational and institutional implementation purposes. The two figures referenced below — the early identification and referral algorithm, and the severity decision tree — are the basis on which the care pathway and severity scale presented in this document were adapted.

"This guideline may be reproduced for educational and implementation purposes."

FIG. 1

Early identification and referral-to-physical-therapy pathway

Source: Sargent B, Coulter C, Cannoy J, Kaplan S. 2024 CMT CPG, Figure 1 (Supplemental Digital Content 1)

FIG. 2

CMT Severity Grading Scale and decision tree (0–12 months)

Source: Sargent B, Coulter C, Cannoy J, Kaplan S. 2024 CMT CPG, Figure 2 (Supplemental Digital Content 2)

See the full guideline (2024 CMT CPG) for the original figures.

How Baby Symmetry addresses the gap described above

Three tools, one single record

The Baby Symmetry platform, by BS3D, was designed to specifically solve the objective, standardized measurement problem described in the previous sections — without requiring any equipment beyond an iPhone.

GonioBaby

A digital goniometer built into a smartphone app, used by a single clinician, to measure and record the infant's cervical rotation and lateral flexion range of motion during the exam.

3D scanning + BS3D mount

An iPhone attached to the BS3D mount performs a cranial scan in minutes, generating an automated cranial asymmetry report to complement the cervical evaluation.

Baby Symmetry Platform

Centralizes ROM measurements, cranial asymmetry reports and patient progress, standardizing data across clinicians and hospital units.

Neonatal screening + digital goniometry + 3D scanning, integrated into a single digital record.

Suggested implementation: maternity ward → pediatric physical therapy outpatient clinic → follow-up

Transparency note

The 2024 CMT CPG (APTA) is an evidence-based guideline that references generic instruments — "arthrodial protractor or goniometer" — validated in specific studies (e.g., Klackenberg et al., Seager et al.), and does not cite or evaluate GonioBaby, the BS3D mount or the Baby Symmetry platform, products that did not exist at the time of the literature review (through June 2023).

The recommendation for early screening, the value of objective measurement, and the CMT Severity Grading Scale are, indeed, established clinical evidence. Adoption of any specific digital tool to enable this recommendation — including the products mentioned here — should go through the hospital's usual evaluation process: accuracy validation against the gold standard, and review by clinical engineering and the patient safety office before adoption into institutional protocol.

What the literature associates with early, well-documented screening

Expected impact of earlier diagnosis

The gains below are attributed, in the guideline, to earlier initiation of physical therapy and objective ROM monitoring — not to any specific product — and serve as a reference for institutional targets.

−73%

Reduction in average treatment time when starting before 1 month vs. 6–12 months (1.5 vs. 9.8 months)

57%

Of physical therapists began classifying CMT severity after the 7/8-grade scale was introduced

↓

Lower need for botulinum toxin or surgery with intervention before 3 months

94%

Of the 17 recommendations in the 2024 guideline were rated "clear" by external reviewers

Next steps for the protocol committee

Checklist for institutional adoption

Define the team responsible for screening in the first 2–3 days of life (nursing, pediatrics or physical therapy)

Aligned with Action Statements 1 and 2

Establish a fast referral pathway to the pediatric physical therapist and the pediatrician

Aligned with Action Statement 3

Standardize documentation of the CMT Severity Grading Scale in the chart

Aligned with Action Statement 9

Technically evaluate digital measurement tools (GonioBaby or equivalents) together with clinical engineering

Step under the hospital's responsibility

Define reassessment criteria between 3 and 12 months after discharge

Aligned with Action Statement 17

Periodically audit average age at first evaluation and resolution rate

Guideline implementation recommendation